Dr Danny Antebi and Stewart Greenwell offer their thoughts on the recent Hussey review of health and social care, and what it would take to turn the recommendations into reality.
A strong case for change in Health and Social Care in Wales is again reinforced by this Parliamentary Review, building on the Well-being of Future Generations Act 2015; Fulfilled Lives, Supportive Communities; Social Services and Well-being Act 2014; Prudent Health Care and Together for Health. The thinking is brought together and developed into a coherent vision for Wales, with recommendations supported by a strong set of arguments.
However, as the authors point out, if the case for change is so compelling, and it is becoming increasingly clear that the health and social care sector is no longer fit for purpose, why has this nettle not been grasped and what prevents public sector organisations from seeing what needs to be done, as part of normal business and responding accordingly?
The recommendations are apposite so we would like to focus on this latter question as the real issue to be addressed.
The answer lies partly in the changes required in individual and system behaviour. Everyone with a part to play must be able to be part of a dialogue which starts something like:
‘How do I/we need to behave differently to notice and respond to changes in demand, technological advances and changes in the economic environment?’ This challenge applies to everyone including Welsh Government staff, frontline staff, politicians, the general public, professional bodies and organisations delivering health and social care:
‘What needs to be different in how I respond on a daily basis, what needs to be different in our health and social care culture and how do we change our structures to support such change?’
Behaviour is more likely to change when there is a clear, relatively simple rationale, an incentive, and specific unambiguous expectations. Our early reaction to this review was that in places the language is complex and peppered with jargon. As relatively seasoned participants, we still found some of it difficult to comprehend and if aiming for a new relationship with the public, this needs to be addressed. The public need to understand it, even if the intended audience is politicians and key professional stakeholders.
Changing the narratives
Peoples’ and organisations’ behaviour is a direct result of their predominant beliefs about their priorities, their objectives and the prevailing narratives. The implications of the review suggest four fundamental changes to those beliefs and narratives.
Firstly, a shift of power in how agenda are set and how decisions are made; from specialist to community, from hospital to neighbourhood, from professional to customer/user of service. So, a move away from large organisations that ‘know best’, to an approach where ordinary people know they have a voice and can seize opportunities to use their voice.
Secondly, there needs to be a shift in the centre of gravity of the delivery of health and social care. Hospital care is seen as separate from community care in both our language and our behaviour, yet hospitals should be seen as an integral part of our communities. The resources in hospitals would become owned by communities and all the specialists and services associated with hospitals, become part of a resource which works on behalf of local people. Thus, a cardiologist or a physiotherapist will see people in the best place for them, as well as offering best value. The result will be more services provided in or near to peoples’ homes, rather than them being sucked into an already overwhelmed hospital. This will also create the conditions for prevention, early intervention and maintaining people near their families and networks, leading to greater investment in community resilience.
Underpinning this, there has to be an understanding of the difference between treatment and care. Professionals offer treatment but a whole system offers care and support. People will often say “the treatment from my doctor, nurse or other professional was excellent but I did not feel cared for, cared about or well informed”.
Thirdly, the current system is supply- rather than demand-led. Services which are not demand-led inevitably become increasingly ineffective, inefficient and more expensive as supply and demand diverge. A good example is a hospital A&E department which is now dealing with a demand different to that for which it was originally designed. The current demands on health and social care are significantly associated with frail older people with several long-term conditions. Their adult children have full time jobs and their own children and juggle caring with running their households. These demands on the system do not translate well into targets and waiting times, even though these are important if you are waiting for a service. We tend to understand demand in terms of numbers of referrals or how long we have to wait, but modelling demand means fully understanding the health and social care needs of those older people throughout the whole system, crafting and recrafting innovative responses.
An example could be listening to what older people say about what is important to them, e.g. getting out in the fresh air, taking gentle exercise and making that happen through introducing them to local activities, rather than ‘referring them’ to another service. Once given the chance to say what is important, that may develop into ‘seeing my grandchildren more frequently’, requiring a different response that may involve discussions with the extended family or making use of volunteer driving schemes. It becomes a whole system approach not an agency task.
Fourthly, there needs to be a focus on value and shared economic objectives rather than costs, cutting budgets and headcounts. Hence the appropriate question becomes: ‘How much does this intervention improve the health outcome for a person/the community?’, rather than: ‘how much does this cost and can we do it cheaper?’ Focusing on ‘value to the person’ has to be objective and negotiated between organisations, moving away from working in silos which costs more, gives people the ‘run-around’ and ultimately poorer clinical outcomes. This should not lead to a financial free-for-all, rather the opposite, a shared responsibility for the outcomes and the economics.
Turning recommendations into reality
Addressing these four fundamentals will create the conditions to act on the ten recommendations. We can build an environment where the beliefs about the purpose of services and the attitudes about working with people and other organisations lead to our behaviour changing. This cannot be done quickly and such huge cultural change will take time, patience and dogged determination.
We would like to address a couple of the recommendations specifically.
‘A great place to work’ and a ‘health and social care system always learning’ go hand in glove. Workers will always enjoy a workplace that encourages and invites learning. Staff would feel able to share ideas, concerns, errors and proposals freely, knowing that they would be treated as assets rather than problems; complaints would be experienced as opportunities to learn and enhance the agency’s reputation. The size of Wales is one of the characteristics conducive to bringing down unhelpful boundaries and reducing silo-working – necessary for the culture change required. The positive culture would be visible and tangible by being clear that ‘this is how we do things around here’. Coaching and action learning would be part of the normal working environment, constantly used and discussed.
Innovation emerges from bringing together people from very different industries and academic disciplines to engage in dialogue. ‘This is my truth, now tell me yours’ is a good place to start and will lead to the paradigm shifts we need.
Patience and humility are seldom mentioned in a discussion about leadership and change, but they create time and opportunities for people to think and be heard. They are not prominent in our current culture because they challenge our ideas about status and pace but they will underpin sustainable change.
We are struck by the learning from Margaret Flynn’s words in relation to accountability and governance in her report into Operation Jasmine, which investigated neglect of older people living in care homes in Wales.
‘Good governance is …… embedded in relationships – with……relatives, friends and advocates and with health and social care practitioners and the wider agencies – of which they are a part.’ (Flynn, 2014)
We firmly believe that good governance and accountability emerge from helpful relationships rather than process and procedure.
The review introduces the ‘quadruple aim’ as an alternative to the well-established and internationally recognised triple aim for health services. Firstly improving the population health and well being through a focus on prevention; secondly improving the experience and quality of care for people; thirdly increasing the value achieved from the funding of health and social care through improvement and innovation. The fourth part of the ‘quadruple aim’ is to to enrich the well being capability and engagement of the health and social care workforce. We would argue that looking after the workforce is an essential enabler of any programme of wholesale change rather than a primary aim and has to be present throughout everything that takes place, reinforcing a whole system approach yet again.
This report endorses the messages delivered by recent policy and legislation, leaving the critical question: ‘if the case is so compelling, why hasn’t it happened?’. We argue that an insufficient number of people and agencies have changed their behaviour because we have not provided strong, compelling and consistent arguments to do so, nor sufficiently detailed expectations. This is partly because the narrative and priorities remain, ‘keep to your budgets, hit your targets and take as few risks as possible’. This needs to change to focus on best value for the person.
The Social Services and Well-Being Act has given an imperative for workers to move from ‘what is wrong and what can I do for you?’ to ‘what matters to you?’ It is a different conversation, with people telling their story and outlining their aspirations. This is a fundamental change in approach for many workers, confirming that technical interventions are only part of the answer for a frail older person.
A change of this magnitude, about which we, along with many others, would be inspired, will need the context to be set and modelled by those in power, i.e. politicians, civil servants and professional bodies.
We are not confident that the body of the report reflects that requirement adequately and if not addressed, the review becomes just another document gathering dust.
‘Do as I do, rather than do as I say’. Boldness and bravery needs to start at the top!
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